Thirty miles south of the border with starving North Korea, young women in the South Korean capital are starving themselves, victims not of famine but of fashion.
Dr. Si Hyung Lee has seen this dark side of affluence and modernity. He remembers best the patient who died of respiratory failure. "She was a pediatrician's daughter," said Lee, director of the Korea Institute of Social Psychiatry at Koryo General Hospital in Seoul. "Her father and mother were both doctors."
But her parents failed to realize that their teenager suffered from anorexia nervosa--a disease almost unheard of in Korea a decade ago--until it was too late to save her.
If Asia is a reliable indicator, eating disorders are going global.
Anorexia--a psychiatric disorder once known as "golden girl syndrome" because it struck primarily rich, white, well-educated young Western women--was first documented in Japan in the 1960s. Eating disorders are now estimated to afflict about 1 in 100 young Japanese women, almost the same incidence as in the United States, according to retired Tokyo University epidemiologist Hiroyuki Suematsu.
Over the past five years, the self-starvation syndrome has spread to women of all socioeconomic and ethnic backgrounds in Seoul, Hong Kong and Singapore, Asian psychiatrists say. Cases also have been reported--though at much lower rates--in Taipei, Beijing and Shanghai. Anorexia has even surfaced among the affluent elite in countries where hunger remains a problem, including the Philippines, India and Pakistan.
Doctors in Japan and South Korea say they also have noticed a marked increase in bulimia, the "binge-purge syndrome" in which patients gorge themselves, then vomit or use laxatives to try to keep from gaining weight, sometimes with lethal consequences.
Experts debate whether these problems are caused by Western pathologies that have infected their cultures via the globalized fashion, music and entertainment media or are a generic ailment of affluence, modernization and the conflicting demands now placed on young women. Either way, the effects are unmistakable.
"Appearance and figure has become very important in the minds of young people," said Dr. Ken Ung of National University Hospital in Singapore. "Thin is in, fat is out. This is interesting, because Asians are usually thinner and smaller-framed than Caucasians, but their aim now is to become even thinner."
In the West, the average body mass index, or BMI, which assesses weight relative to height and determines body composition, ranges from 20 to 25 for a healthy young female, Ung said. Among young Chinese women, the average BMI is 20, he said.
Nevertheless, a weight-loss craze has swept the developed countries of Asia, sending women of all ages--as well as some men--scurrying to exercise studios and slimming salons.
Liposuction surgeons have popped up in Seoul, as have diet powders and pills, cellulite creams, weight-loss teas and other herbal concoctions "guaranteed" to melt away the pounds.
Anything to Be Thin
In Hong Kong, 20 to 30 types of diet pills are in common use, including variations on the "fen-phen" combination of fenfluramine and phentermine that was banned in the United States last month for causing heart damage, said Dr. Sing Lee, a psychiatrist at the Chinese University of Hong Kong who has written extensively on eating disorders. Though the Health Ministry has asked pharmaceutical companies to withdraw the offending drugs, "I'm sure new ones will be coming out right away," Lee said.
In Singapore, where the anorexia death of a 21-year-old, 70-pound student at the prestigious National University made headlines last year, dieting itself has become a fashion statement. On Orchard Road, the city's toniest shopping district, a hot-selling T-shirt designed by "essence" bears this stream-of-consciousness essay on modern female angst:
"I've got to get into that dress. It's easy. Don't eat . . . I'm hungry. Can't eat breakfast. But I ought to . . . I like breakfast. I like that dress . . . Still too big for that dress. Hmm. Life can be cruel."
In Japan, where dieting is less a trend than a way of life for many young women, the principle that thinner is better is now being applied to facial beauty. A recent subway flier for a young women's magazine pictured an attractive model complaining, "My face is too fat!"
Drugstores and beauty salons offer face-reducing seaweed creams, massage, steam and vibration treatments and even Darth Vader-esqe facial masks designed to promote sweating.
The Takano Yuri Beauty Clinic chain, for example, now offers a 70-minute "facial slimming treatment course" for $157 at 160 salons across Japan, and reports that business is booming.
South Korea is perhaps the most interesting case study since, until the 1970s, full-figured women were seen as more sexually attractive--and more likely to produce healthy sons, South Korea's Lee said. "When I was a kid, plumper-than-average women were considered more desirable; they could be a first son's wife in a good house," he said.
But standards of beauty have changed dramatically in the 1990s with democratization as South Korea's government has decontrolled TV and newspapers, allowing in a flood of foreign and foreign-influenced programming, information and advertising.
By 1994, a study by the Korea Institute of Food Hygiene found that 90% of high school girls who were of normal weight, as defined by a BMI of 20 to 25, believed themselves to be overweight.
A follow-up study the next year found that Korean women were, in fact, getting skinnier. The institute's 1995 survey of 6,700 adults older than 20 found that 21.3% of women were underweight, with a BMI of less than 20, a 2.5% percent increase from 1994. Some 19.7% were overweight, while only 2.2% were classified as obese.
A recent newspaper article about the changing dimensions of Miss Korea beauty queens confirmed what many Korean women already suspected: While the height of the successful contestants has risen steadily, from 5 feet 4 in 1975 to 5 feet 7 in 1995, their weight has not budged over 112 pounds.
"The 'be slim' trend starts earlier now, even in elementary school," said the institute's Dr. Kim Cho Il. "They shun overweight boys and girls--especially girls--as their friends."
Dieting by growing teenagers often leads to inadequate calcium intake and weaker bones. Kim is worried about an increase in osteoporosis cases when this generation of girls reaches menopause.
"The dieting will also result in weaker physiques and lessened resistance against disease," she said.
Meanwhile, women in their 20s worry that employers and prospective spouses will pass them by if they are plump.
Some of Lee's eating-disorder patients started dieting after being nagged by mothers to lose weight to find a husband. Most of the anorexic patients tend to be serious, studious, obedient young women who do not think there is anything wrong with them and who usually are dragged into the clinic by frantic parents, Lee said.
"If they are skinnier than average, Koreans decide there must be something medically wrong with them, so first they take them to the herb doctor" for a deer-horn powder that is thought to "build up their spiritual as well as physical forces," Lee said. A 20-day course of deer-horn treatment costs about $1,095, he said.
Many of these young women are misdiagnosed as having stomach problems or other ailments before at last being referred for psychiatric help, he said.
Many bulimia sufferers never seek medical attention, and since they tend to be secretive about their condition, psychiatrists said there are no reliable statistics about incidences of the condition.
South Korea's only survey of eating disorders, conducted among college students in 1990, found that 0.7% suffered from anorexia and 0.8% from bulimia, but those rates "may be a little higher now," said Han O Soo, a neuropsychiatrist at Central Hyundai Hospital.
Recent studies in the United States have concluded that roughly 1% of women ages 18 to 35 suffer from anorexia and from 6% to 12% may suffer to some degree from bulimia. Comprehensive studies of the incidences of anorexia and bulimia have not been conducted in Asian nations.
South Korean psychiatrist Dr. Kim Joon Ki, who spent a year in Japan studying eating disorders, said the increase in such pathologies over the past few years has been phenomenal. "Before I went to Japan in 1991, I had seen only one anorexia patient," Kim said. "In Japan they told me, 'Korea will be next, so you should study this now.' And sure enough, they were right."
Kim said he has seen more than 200 patients, about half of whom were anorexic and half bulimic, in the 2 1/2 years since he opened a private eating-disorder clinic. "Lately I have so many calls that I can't even give them all appointments," he said.
But Kim said his new book on eating problems, "I Want to Eat but I Want to Lose Weight," is selling poorly. "Readers' attention is still focused on dieting, not on eating disorders," he said.
Dieting is not only trendy, it's a necessity for many South Korean women who want to fit into the most fashionable clothes--some of which are made in only one small size that is the equivalent of an American size 4, said Park Sung Hye, 27, a fashion editor at Ceci, a popular monthly style magazine for 18- to 25-year-old women.
"They make just one size so only skinny girls will wear it and it will look good," Park said. "They think, 'We don't want fatty girls wearing our clothes because it will look bad and our image will go down.' "
As a result, "If you're a little bit fatty girl, you cannot buy clothes," she said. "All of society pushes women to be thin. America and Korea and Japan all emphasize dieting."
Park said eating disorders are increasing but still are relatively rare. "If, say, 100 people are dieting, maybe two or three have bulimia or anorexia, so it's not enough to worry about," she said. But in the articles she writes on how to diet, she cautions readers against excess, warning, "A model's body is abnormal, not normal."
'Everything Has a Price'
Park said young Koreans' attitudes toward food differ from those of their elders, who remember hunger after World War II and the old greeting, "Have you eaten?" and fat as a sign of prosperity. "Now skinny [means you are] more wealthy, since everyone can eat three times a day," Park said.
Young women interviewed in Seoul's swanky Lotte department store said dieting is a necessary evil.
"Boys don't like plump girls," said Chung Sung Hee, 19, who at 5 feet and 95 pounds considers herself overweight. "I don't know whether they are serious or not, but sometimes they say I'm plump. . . . So I try to lose weight. I go without food, and my friends use milk diets or juice diets, but we don't last that long."
Han Soon Nam, 29, an advertising company employee, said of dieting: "I don't think it's good, but it is the fashion. Everything has a price. You lose your health to get skinnier."
Several psychiatrists blamed the global media's ubiquitous use of hyper-thin supermodels, movie stars and pop music figures for broadcasting an unrealistic female beauty ideal around the globe--and said they think it is unstoppable.
"The women's magazines do run articles about the dangers of dieting, but in the same issue they run stories about how to lose weight," said Kozo Shimosaka, a Japanese psychiatrist who has been studying eating disorders since 1961. "Apparently, if you don't have a diet article in your magazine, it won't sell."
Singapore's Ung observed: "I don't think you can block the media message. Singapore is pretty good about censoring stuff, but there's a limit to what you can control."
But Hong Kong's Lee believes that it is not the media that are to blame for the increase in eating disorders, but underlying problems. These can include low self-esteem, sexual abuse, academic failure, difficulties with parents and conflicts between women's traditional roles and the growing demands that they achieve educational and career success as well, he said.
"The cultural prevention is not to give Prozac or prescribe psychotherapy, but to find social means to empower women," Lee said. "Society judges women far too physically."